The stories have now been relegated to the back pages. “… Smoldering
batteries forced safety regulators to ground Boeing’s new 787 Dreamliner
jets.” This is a glimpse into the challenges that this aircraft and
company seem to have been besieged by. The recent grounding of the fleet
comes on the heels of other safety related incidents that while
“typical” with a new plane have caused some concern given the rapid
sequencing of events.

By the estimates made by the Institute of Medicine in early 2000,
deaths from mistakes in healthcare are associated with the equivalent of
one of these planes falling out of the sky every single day. The high
estimate was of 98,000 people a year dying as a result of preventable
harm and error.

What has been remarkable to me about the Boeing story, is not so much
the incidents, not so much that the fuel leaked, or that the cockpit
alarm went off or that it took forty minutes for a fire to be
extinguished, what’s remarkable to me is that these are the stories,
these are the headlines that we are reading and that the TV networks are
carrying.

These “incidents,” for those of us who work in healthcare, are what
we refer to as “near misses” and “good catches.” No one has died, no one
has been injured, and no one has suffered anything more I suspect than a
delay in getting to his or her destination. Oh, and some bruised pride
and quarterly earnings impact for Boeing I expect.

In our hospitals, these “incidents”, these “near misses” rarely get
reported internally; the associated press and the national evening news
certainly don’t pick them up as front page stories.

If we are obsessed with safety, like the human factors focused
airline industry, our near misses and our good catches would be enough
for us to stop the line, stand back and work to develop safer systems.

So what can leaders do?

Lead a culture where you model that it is safe to speak up and
encourage people to call out near misses, report good catches and model
the mindset and actions of being personally accountable.

Make it known that while clear roles and clarity around authority are
important, everyone is personally empowered to speak up or call an
unsafe or potentially unsafe behavior to the attention of their
colleagues.

Use all meetings, from the board to the bedside, to tell stories of
how a mistake was avoided and how, when things go wrong, you recovered.

When things do go wrong because they will, we are human beings caring
for human beings, don’t point fingers and blame people. Own the
outcome, work to learn from the failure, apologize, atone and remain
open to feedback.

Adopt some of the human error mitigation systems that the airlines
have embraced. First names only and the sterile cockpit rule require
that people only address each other by their first names in the cockpit
and that during specific times only conversations pertinent to flying
the plane are permitted. We have a choice to hold ourselves to these
relatively simple agreements in our operating rooms and exam rooms.

So yes, I wish my hospital was a Dreamliner. Because Dreamliners are
not falling out of the sky; they are being stopped, checked, called
back and inspected.

2 comments:

Linda Menzies Greenstein
said...

From Facebook:

As someone that worked at teaching hospitals for many years and then became a parent of a critically ill, child I applaud Richard's ideas. Even the most talented professionals and prestigious hospitals make mistakes. I was fortunate enough to work in and be a patient family member at hospitals that welcomed questions and listened to safety concerns.